{"id":4936,"date":"2025-11-27T06:34:22","date_gmt":"2025-11-27T12:34:22","guid":{"rendered":"https:\/\/alabamarespite.wpenginepowered.com\/?page_id=4936"},"modified":"2025-12-01T12:56:56","modified_gmt":"2025-12-01T18:56:56","slug":"reimbursement-info-for-applicants-spanish-r1-2023","status":"publish","type":"page","link":"https:\/\/alabamarespite.org\/es\/apply-for-respite\/reimbursement-info-for-applicants-spanish-r1-2023\/","title":{"rendered":"Reimbursement Info for Applicants &#8211; Spanish R1 2023"},"content":{"rendered":"\r\n<p>\u00bfEs usted un cuidador familiar (padre, guardi\u00e1n o familiar) sin compensaci\u00f3n monetaria por los cuidados de tiempo completo a un ser querido de cualquier edad con una enfermedad cr\u00f3nica o discapacidad que requiere atenci\u00f3n las 24 horas? \u00bfNecesita un descanso (tambi\u00e9n conocido como respiro)? Si es as\u00ed, lo invitamos a * solicitar el programa de Reembolso de Respiro de Vida \u00fatil de Alabama.<\/p>\r\n\r\n\r\n\r\n<p>Si solicit\u00f3 y recibi\u00f3 un reembolso por cuidado de relevo de Alabama Lifespan Respite despu\u00e9s del 1 de septiembre de 2025, no es necesario que vuelva a presentar la solicitud. La informaci\u00f3n de reinscripci\u00f3n se enviar\u00e1 anualmente a los destinatarios antes del 31 de agosto<\/p>\r\n<p><strong> AVISO:<\/strong> El completar esta solicitud no garantiza la concesi\u00f3n de asistencia financiera de Alabama Lifespan Respite. Tenga en cuenta que si bien Alabama Lifespan Respite desea que podamos ayudar a todas las personas calificadas que buscan asistencia, lamentablemente solo tenemos fondos limitados para satisfacer las necesidades de los cuidadores calificados. Por lo tanto, solo podemos responder a las solicitudes en funci\u00f3n de nuestros recursos disponibles.<\/p>\r\n<p>&nbsp;<\/p>\r\n<p style=\"text-align: center;\"><strong>Questions? Email al.respite@ucphuntsville.org or call 256-859-8300<\/strong><\/p>\r\n<p style=\"text-align: center;\">Estoy de acuerdo en usar los fondos de reembolso de relevo solo para el cuidado de relevo.<\/p>\r\n<p style=\"text-align: center;\"><strong>\u00a0Acerca del Programa de Reembolso de Respiro de Alabama \u00bfQu\u00e9 es el relevo<\/strong><\/p>\r\n<p><strong>\u00bfQu\u00e9 es el relevo?<\/strong> Un breve descanso temporal para aliviar a los cuidadores familiares de las extraordinarias demandas intensivas de brindar atenci\u00f3n continua en el hogar a un ser querido<br \/>con necesidades especiales.<\/p>\r\n<p><strong>\u00bfQui\u00e9n es un cuidador principal?<\/strong> Una persona que proporciona atenci\u00f3n no remunerada a tiempo completo (40 horas o m\u00e1s por semana) para ayudar con las actividades de la vida diaria (ba\u00f1arse, vestirse, alimentarse, administrar medicamentos, recados, tareas dom\u00e9sticas, etc.) para un padre, c\u00f3nyuge \/ pareja. ni\u00f1o, hermano, abuelo u otro miembro de la familia que requiera atenci\u00f3n de tiempo completo debido a una discapacidad o enfermedad cr\u00f3nica.\u00a0<\/p>\r\n<p><strong>\u00bfQui\u00e9n es un beneficiario de la atenci\u00f3n?<\/strong> Un miembro de la familia que requiere atenci\u00f3n de tiempo completo debido a una discapacidad o enfermedad cr\u00f3nica (se requiere prueba de<br \/>diagn\u00f3stico).<\/p>\r\n<p><strong>\u00bfQui\u00e9n es un proveedor de servicios de relevo?<\/strong> Una persona contratada por el cuidador\u00a0 principal para darles un breve descanso (respiro) de las tareas diarias de cuidado. La prestaci\u00f3n<br \/>de servicios de relevo en el lugar, los programas de relevo diurno \/ nocturno y los campamentos de pago tambi\u00e9n son elegibles para reembolso.<\/p>\r\n<p><strong>\u00bfQu\u00e9 es el reembolso por servicios de relevo?<\/strong> Alabama Lifespan Respite no emplea proveedores de servicios de relevo. Por lo tanto, los cuidadores son responsables de identificar, contratar y capacitar a los proveedores de relevo (o inscribir a su beneficiario de cuidado en un programa o campamento diurno \/ nocturno) para recibir relevo y ser\u00e1n reembolsados por los servicios prestados seg\u00fan las pautas de la hoja de tiempo. El reembolso no es un ingreso y no deber\u00eda afectar los beneficios de SSI<\/p>\r\n<p><strong>\u00bfQu\u00e9 son las hojas de tiempo trabajadas?<\/strong> Las hojas de tiempo son simplemente un formulario en papel que documenta cu\u00e1ndo y durante cu\u00e1nto tiempo se llev\u00f3 a cabo el relevo y qui\u00e9n<br \/>proporcion\u00f3 el relevo (Proveedor de relevo)<\/p>\r\n<p>C\u00f3mo funciona el programa: una vez que un cuidador solicita el programa de reembolso de relevo y califica para el programa de respiro, el cuidador recibir\u00e1 un paquete de bienvenida con<br \/>instrucciones y una hoja de tiempo que indica el monto del reembolso que recibir\u00e1 durante un per\u00edodo de tiempo espec\u00edfico.<\/p>\r\n<p>Los cuidadores pueden elegir a cualquier persona que deseen que les brinde un respiro y pueden requerir capacitaci\u00f3n (como resucitaci\u00f3n cardiopulmonar o primeros auxilios b\u00e1sicos), si as\u00ed lo<br \/>desean, pero el nivel de capacitaci\u00f3n queda a discreci\u00f3n del cuidador. El proveedor de servicios de relevo debe tener al menos 18 a\u00f1os de edad y no puede vivir en el mismo hogar que el beneficiario de la atenci\u00f3n. M\u00e1s de un proveedor de servicios de relevo puede brindar relevo durante las fechas indicadas en la hoja de asistencia y ser registrado como tal. Los cuidadores \/ proveedores de servicios de relevo determinan mutuamente una tarifa de pago.<\/p>\r\n<p style=\"text-align: center;\"><strong>Questions? Email al.respite@ucphuntsville.org or call 256-859-8300<\/strong><\/p>\r\n<p>Cuando se completa el servicio de relevo, el proveedor de relevo firma la hoja de tiempo para confirmar la fecha y hora en que se recibi\u00f3 el relevo. El cuidador pagar\u00e1 al proveedor de relevo<br \/>de su bolsillo y enviar\u00e1 la hoja de tiempo completada \/ firmada a Alabama Lifespan Respite, quien emitir\u00e1 un cheque para reembolsar al cuidador (seg\u00fan el monto de la recompensa que debe utilizarse durante el per\u00edodo de tiempo especificado). Una vez que Alabama Lifespan Respite reciba la hoja de tiempo completada \/ firmada y verifique la informaci\u00f3n, se emitir\u00e1 el reembolso al cuidador en un plazo de 30 d\u00edas.<\/p>\r\n<p>\r\n\r\n<style id=\"wpforms-css-vars-4882-block-9bdee9de-56d0-4d50-96ed-aacc9e62ba9a\">\n\t\t\t\t#wpforms-4882.wpforms-block-9bdee9de-56d0-4d50-96ed-aacc9e62ba9a {\n\t\t\t\t--wpforms-field-size-input-height: 43px;\n--wpforms-field-size-input-spacing: 15px;\n--wpforms-field-size-font-size: 16px;\n--wpforms-field-size-line-height: 19px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 16px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 1;\n--wpforms-label-size-font-size: 16px;\n--wpforms-label-size-line-height: 19px;\n--wpforms-label-size-sublabel-font-size: 14px;\n--wpforms-label-size-sublabel-line-height: 17px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n--wpforms-container-shadow-size-box-shadow: none;\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-block wpforms-block-9bdee9de-56d0-4d50-96ed-aacc9e62ba9a wpforms-render-modern\" id=\"wpforms-4882\"><form id=\"wpforms-form-4882\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"4882\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/es\/wp-json\/wp\/v2\/pages\/4936?wpforms_form_id=4882\" data-token=\"a39931f0eecd98c60da6837cb3b3ae11\" data-token-time=\"1777203959\"><noscript class=\"wpforms-error-noscript\">Por favor, activa JavaScript en tu navegador para completar este formulario.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Por favor, activa JavaScript en tu navegador para completar este formulario.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-4882-field_157-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"157\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-4882-field_158-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"158\"><div id=\"wpforms-4882-field_158\" aria-errormessage=\"wpforms-4882-field_158-error\"><b>LISTA DE VERIFICACI\u00d3N:<\/b> Marque que ha le\u00eddo y comprendido cada una de las siguientes pautas antes de solicitar el programa de reembolso de Alabama Lifespan Respite<\/div><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-4882-field_159-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"159\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Checkboxes <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-4882-field_159\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_159_1\" name=\"wpforms[fields][159][]\" value=\"Entiendo que actualmente no puedo recibir servicios de relevo a trav\u00e9s de ning\u00fan otro programa para calificar para el programa de reembolso de Alabama Lifespan Respite.\" aria-errormessage=\"wpforms-4882-field_159_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_159_1\">Entiendo que actualmente no puedo recibir servicios de relevo a trav\u00e9s de ning\u00fan otro programa para calificar para el programa de reembolso de Alabama Lifespan Respite.<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_159_2\" name=\"wpforms[fields][159][]\" value=\"Entiendo que solo un cuidador por hogar es elegible para presentar una solicitud\" aria-errormessage=\"wpforms-4882-field_159_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_159_2\">Entiendo que solo un cuidador por hogar es elegible para presentar una solicitud<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_159_3\" name=\"wpforms[fields][159][]\" value=\"Entiendo que solo una persona por hogar puede figurar como beneficiario de la atenci\u00f3n. (Si est\u00e1 cuidando a varias personas con necesidades especiales, enumere solo la persona que requiere la mayor atenci\u00f3n).\" aria-errormessage=\"wpforms-4882-field_159_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_159_3\">Entiendo que solo una persona por hogar puede figurar como beneficiario de la atenci\u00f3n. (Si est\u00e1 cuidando a varias personas con necesidades especiales, enumere solo la persona que requiere la mayor atenci\u00f3n).<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_159_4\" name=\"wpforms[fields][159][]\" value=\"Entiendo que no puedo figurar como cuidador principal y proveedor de relevo, y que la intenci\u00f3n de este programa es reembolsarme despu\u00e9s de haber pagado a un tercero por el relevo.\" aria-errormessage=\"wpforms-4882-field_159_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_159_4\">Entiendo que no puedo figurar como cuidador principal y proveedor de relevo, y que la intenci\u00f3n de este programa es reembolsarme despu\u00e9s de haber pagado a un tercero por el relevo.<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_159_5\" name=\"wpforms[fields][159][]\" value=\"Entiendo que debo presentar un comprobante de diagn\u00f3stico para el beneficiario de mi cuidado, que es necesario para procesar mi solicitud.\" aria-errormessage=\"wpforms-4882-field_159_5-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_159_5\">Entiendo que debo presentar un comprobante de diagn\u00f3stico para el beneficiario de mi cuidado, que es necesario para procesar mi solicitud.<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_159_6\" name=\"wpforms[fields][159][]\" value=\"Entiendo que soy responsable de seleccionar y capacitar a un proveedor de servicios de relevo de confianza que tenga al menos 18 a\u00f1os de edad y que viva fuera del hogar del beneficiario de la atenci\u00f3n. Ni Alabama Lifespan Respite ni UCP Huntsville ser\u00e1n responsables de las acciones tomadas por mi proveedor de relevo seleccionado\" aria-errormessage=\"wpforms-4882-field_159_6-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_159_6\">Entiendo que soy responsable de seleccionar y capacitar a un proveedor de servicios de relevo de confianza que tenga al menos 18 a\u00f1os de edad y que viva fuera del hogar del beneficiario de la atenci\u00f3n. Ni Alabama Lifespan Respite ni UCP Huntsville ser\u00e1n responsables de las acciones tomadas por mi proveedor de relevo seleccionado<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_159_7\" name=\"wpforms[fields][159][]\" value=\"Entiendo que hay un per\u00edodo de procesamiento de &lt;b&gt;30 d\u00edas antes de recibir el reembolso en forma de cheque. &lt;\/b&gt;Si no puedo esperar entre 30 d\u00edas para recibir el reembolso, entiendo que este programa no se ajusta a mis necesidades y no presentar\u00e9 una solicitud para el programa.\" aria-errormessage=\"wpforms-4882-field_159_7-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_159_7\">Entiendo que hay un per\u00edodo de procesamiento de <b>30 d\u00edas antes de recibir el reembolso en forma de cheque. <\/b>Si no puedo esperar entre 30 d\u00edas para recibir el reembolso, entiendo que este programa no se ajusta a mis necesidades y no presentar\u00e9 una solicitud para el programa.<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_159_8\" name=\"wpforms[fields][159][]\" value=\"Estoy de acuerdo en usar los fondos de reembolso de relevo solo para el cuidado de relevo\" aria-errormessage=\"wpforms-4882-field_159_8-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_159_8\">Estoy de acuerdo en usar los fondos de reembolso de relevo solo para el cuidado de relevo<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-4882-field_16-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"16\"><div id=\"wpforms-4882-field_16\" aria-errormessage=\"wpforms-4882-field_16-error\"><h2 style=\"text-align:center;\">Reimbursement Info for Applicants<\/h2>\r\n<\/div><\/div><div id=\"wpforms-4882-field_18-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"18\"><div id=\"wpforms-4882-field_18\" aria-errormessage=\"wpforms-4882-field_18-error\"><h3 style=\"margin-bottom:10px;\">Solicitud de Relevo de Alabama\r\n<\/h3>\r\n<\/div><\/div><div id=\"wpforms-4882-field_17-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"17\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-4882-field_1-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-4882-field_1\">Nombre del Cuidador: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4882-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" aria-errormessage=\"wpforms-4882-field_1-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-4882-field_19-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-4882-field_19\">Apellido: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4882-field_19\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][19]\" aria-errormessage=\"wpforms-4882-field_19-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-4882-field_21-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-4882-field_21\">Primer nombre, inicial del segundo nombre: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4882-field_21\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][21]\" aria-errormessage=\"wpforms-4882-field_21-error\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-4882-field_23-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-4882-field_23\">Direcci\u00f3n del Cuidador (# Calle, Apto. #, PO): <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4882-field_23\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][23]\" aria-errormessage=\"wpforms-4882-field_23-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-4882-field_25-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"25\"><label class=\"wpforms-field-label\" for=\"wpforms-4882-field_25\">Ciudad, Estado, C\u00f3digo Postal:  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4882-field_25\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][25]\" aria-errormessage=\"wpforms-4882-field_25-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-4882-field_26-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"26\"><label class=\"wpforms-field-label\" for=\"wpforms-4882-field_26\">Condado: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4882-field_26\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][26]\" aria-errormessage=\"wpforms-4882-field_26-error\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-4882-field_91-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"91\"><label class=\"wpforms-field-label\" for=\"wpforms-4882-field_91\">Fecha de nacimiento del cuidador: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-4882-field_91\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][91][date]\" aria-errormessage=\"wpforms-4882-field_91-error\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-4882-field_92-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"92\"><fieldset><legend class=\"wpforms-field-label\">Caregiver Gender: (copy) <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-4882-field_92\" class=\"wpforms-randomize wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_92_1\" name=\"wpforms[fields][92][]\" value=\"Female\" aria-errormessage=\"wpforms-4882-field_92_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_92_1\">Female<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_92_2\" name=\"wpforms[fields][92][]\" value=\"Male\" aria-errormessage=\"wpforms-4882-field_92_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_92_2\">Male<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_92_3\" name=\"wpforms[fields][92][]\" value=\"Other\" aria-errormessage=\"wpforms-4882-field_92_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_92_3\">Other<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-4882-field_93-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"93\"><fieldset><legend class=\"wpforms-field-label\">M\u00e9todo de contacto preferido: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-4882-field_93\" class=\"wpforms-randomize wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_93_1\" name=\"wpforms[fields][93][]\" value=\"Correo electr\u00f3nico\" aria-errormessage=\"wpforms-4882-field_93_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_93_1\">Correo electr\u00f3nico<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_93_2\" name=\"wpforms[fields][93][]\" value=\"Correo postal\" aria-errormessage=\"wpforms-4882-field_93_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_93_2\">Correo postal<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-4882-field_94-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"94\"><label class=\"wpforms-field-label\" for=\"wpforms-4882-field_94\">Direcci\u00f3n de correo electr\u00f3nico: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-4882-field_94\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][94]\" spellcheck=\"false\" aria-errormessage=\"wpforms-4882-field_94-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-4882-field_98-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"98\"><label class=\"wpforms-field-label\" for=\"wpforms-4882-field_98\">N\u00famero de tel\u00e9fono con c\u00f3digo de \u00e1rea: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-4882-field_98\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][98]\" aria-label=\"N\u00famero de tel\u00e9fono con c\u00f3digo de \u00e1rea:\" aria-errormessage=\"wpforms-4882-field_98-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-4882-field_96-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"96\"><fieldset><legend class=\"wpforms-field-label\">\u00bfSu ingreso bruto mensual es superior a $1,500? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-4882-field_96\" class=\"wpforms-randomize wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_96_1\" name=\"wpforms[fields][96][]\" value=\"S\u00ed\" aria-errormessage=\"wpforms-4882-field_96_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_96_1\">S\u00ed<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_96_2\" name=\"wpforms[fields][96][]\" value=\"No\" aria-errormessage=\"wpforms-4882-field_96_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_96_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-4882-field_97-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"97\"><fieldset><legend class=\"wpforms-field-label\">1. \u00bfC\u00f3mo se relaciona usted (cuidador principal) con el destinatario de la atenci\u00f3n? Marque uno a continuaci\u00f3n. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-4882-field_97\" class=\"wpforms-randomize wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_97_1\" name=\"wpforms[fields][97][]\" value=\"Padre\" aria-errormessage=\"wpforms-4882-field_97_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_97_1\">Padre<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_97_2\" name=\"wpforms[fields][97][]\" value=\"C\u00f3nyuge o pareja\" aria-errormessage=\"wpforms-4882-field_97_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_97_2\">C\u00f3nyuge o pareja<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_97_3\" name=\"wpforms[fields][97][]\" value=\"Ni\u00f1o\" aria-errormessage=\"wpforms-4882-field_97_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_97_3\">Ni\u00f1o<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_97_4\" name=\"wpforms[fields][97][]\" value=\"Tutor legal designado por el tribunal\" aria-errormessage=\"wpforms-4882-field_97_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_97_4\">Tutor legal designado por el tribunal<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_97_5\" name=\"wpforms[fields][97][]\" value=\"Hermano\" aria-errormessage=\"wpforms-4882-field_97_5-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_97_5\">Hermano<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_97_6\" name=\"wpforms[fields][97][]\" value=\"Abuelo\" aria-errormessage=\"wpforms-4882-field_97_6-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_97_6\">Abuelo<\/label><\/li><\/ul><\/fieldset><\/div>\t\t<div id=\"wpforms-4882-field_2-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"2\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-4882-field_2\" >estipendio llame 1.<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-4882-field_2\" class=\"wpforms-field-medium\" name=\"wpforms[fields][2]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-4882-field_99-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"99\"><label class=\"wpforms-field-label\" for=\"wpforms-4882-field_99\">Otro (describa):<\/label><textarea id=\"wpforms-4882-field_99\" class=\"wpforms-field-medium\" name=\"wpforms[fields][99]\" aria-errormessage=\"wpforms-4882-field_99-error\" ><\/textarea><\/div><div id=\"wpforms-4882-field_100-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"100\"><fieldset><legend class=\"wpforms-field-label\">2. Especifique el estado militar: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-4882-field_100\" class=\"wpforms-randomize wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_100_1\" name=\"wpforms[fields][100][]\" value=\"Servido\" aria-errormessage=\"wpforms-4882-field_100_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_100_1\">Servido<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_100_2\" name=\"wpforms[fields][100][]\" value=\"Activo\" aria-errormessage=\"wpforms-4882-field_100_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_100_2\">Activo<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_100_3\" name=\"wpforms[fields][100][]\" value=\"Retirado\" aria-errormessage=\"wpforms-4882-field_100_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_100_3\">Retirado<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_100_4\" name=\"wpforms[fields][100][]\" value=\"Nunca servido\" aria-errormessage=\"wpforms-4882-field_100_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_100_4\">Nunca servido<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-4882-field_101-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"101\"><fieldset><legend class=\"wpforms-field-label\">3. Seleccione su raza: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-4882-field_101\" class=\"wpforms-randomize wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_101_1\" name=\"wpforms[fields][101][]\" value=\"Asi\u00e1tico o asi\u00e1tico americano\" aria-errormessage=\"wpforms-4882-field_101_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_101_1\">Asi\u00e1tico o asi\u00e1tico americano<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_101_2\" name=\"wpforms[fields][101][]\" value=\"Birracial o multirracial\" aria-errormessage=\"wpforms-4882-field_101_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_101_2\">Birracial o multirracial<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_101_3\" name=\"wpforms[fields][101][]\" value=\"Negro o afroamericano\" aria-errormessage=\"wpforms-4882-field_101_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_101_3\">Negro o afroamericano<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_101_4\" name=\"wpforms[fields][101][]\" value=\"Nativo de Haw\u00e1i o de las islas del Pac\u00edfico\" aria-errormessage=\"wpforms-4882-field_101_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_101_4\">Nativo de Haw\u00e1i o de las islas del Pac\u00edfico<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-4882-field_102-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"102\"><fieldset><legend class=\"wpforms-field-label\">\u00bfPreguntas? Env\u00ede un correo electr\u00f3nico a al.respite@ucphuntsville.org o llame al 256- 859-8300 <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-4882-field_102\" class=\"wpforms-randomize wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_102_1\" name=\"wpforms[fields][102][]\" value=\"Blanco\" aria-errormessage=\"wpforms-4882-field_102_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_102_1\">Blanco<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-4882-field_103-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"103\"><label class=\"wpforms-field-label\" for=\"wpforms-4882-field_103\">Continuaci\u00f3n de la informaci\u00f3n del cuidador principal: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-4882-field_103\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][103]\" aria-errormessage=\"wpforms-4882-field_103-error\" required><\/textarea><\/div><div id=\"wpforms-4882-field_105-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"105\"><fieldset><legend class=\"wpforms-field-label\">4. Por favor identifique su origen \u00e9tnico. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-4882-field_105\" class=\"wpforms-randomize wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_105_1\" name=\"wpforms[fields][105][]\" value=\"Hispano o Latino\" aria-errormessage=\"wpforms-4882-field_105_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_105_1\">Hispano o Latino<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_105_2\" name=\"wpforms[fields][105][]\" value=\"No Hispano o Latino\" aria-errormessage=\"wpforms-4882-field_105_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_105_2\">No Hispano o Latino<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_105_3\" name=\"wpforms[fields][105][]\" value=\"Negro o afroamericano\" aria-errormessage=\"wpforms-4882-field_105_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_105_3\">Negro o afroamericano<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_105_4\" name=\"wpforms[fields][105][]\" value=\"Nativo de Haw\u00e1i o de las islas del Pac\u00edfico\" aria-errormessage=\"wpforms-4882-field_105_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_105_4\">Nativo de Haw\u00e1i o de las islas del Pac\u00edfico<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-4882-field_106-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"106\"><fieldset><legend class=\"wpforms-field-label\">5. \u00bfLa persona que cuida a vivir con usted o vive usted con ellos? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-4882-field_106\" class=\"wpforms-randomize wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_106_1\" name=\"wpforms[fields][106][]\" value=\"S\u00ed\" aria-errormessage=\"wpforms-4882-field_106_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_106_1\">S\u00ed<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_106_2\" name=\"wpforms[fields][106][]\" value=\"No\" aria-errormessage=\"wpforms-4882-field_106_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_106_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-4882-field_107-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"107\"><fieldset><legend class=\"wpforms-field-label\">6. \u00bfCu\u00e1ntas horas de atenci\u00f3n brinda en una semana (estimaci\u00f3n favor)? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-4882-field_107\" class=\"wpforms-randomize wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_107_1\" name=\"wpforms[fields][107][]\" value=\"Menos que 40\" aria-errormessage=\"wpforms-4882-field_107_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_107_1\">Menos que 40<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_107_2\" name=\"wpforms[fields][107][]\" value=\"Entre 40-60\" aria-errormessage=\"wpforms-4882-field_107_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_107_2\">Entre 40-60<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_107_7\" name=\"wpforms[fields][107][]\" value=\"Entre 60-80\" aria-errormessage=\"wpforms-4882-field_107_7-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_107_7\">Entre 60-80<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_107_8\" name=\"wpforms[fields][107][]\" value=\"80+\" aria-errormessage=\"wpforms-4882-field_107_8-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_107_8\">80+<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-4882-field_109-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"109\"><fieldset><legend class=\"wpforms-field-label\">7. \u00bfEst\u00e1 interesado en recibir informaci\u00f3n sobre un estipendio por servicios de asesoramiento sobre salud mental? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-4882-field_109\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-4882-field_109_1\" name=\"wpforms[fields][109]\" value=\"S\u00ed\" aria-errormessage=\"wpforms-4882-field_109_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_109_1\">S\u00ed<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-4882-field_109_2\" name=\"wpforms[fields][109]\" value=\"No\" aria-errormessage=\"wpforms-4882-field_109_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_109_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-4882-field_110-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"110\"><label class=\"wpforms-field-label\" for=\"wpforms-4882-field_110\">8. En una escala del 1 al 10 (1 es poco o nada de estr\u00e9s y 10 muy estresado), determine su nivel de estr\u00e9s en este momento. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-4882-field_110\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][110]\" aria-errormessage=\"wpforms-4882-field_110-error\" required><\/textarea><\/div><div id=\"wpforms-4882-field_49-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"49\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-4882-field_50-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-trigger\" data-field-id=\"50\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Medicaid Waiver Home Based Service (solo relevo, no seguro m\u00e9dico)<\/legend><ul id=\"wpforms-4882-field_50\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_50_1\" name=\"wpforms[fields][50][]\" value=\"Medicaid Waiver Home Based Services (respite only, not health insurance)\" aria-errormessage=\"wpforms-4882-field_50_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_50_1\">Medicaid Waiver Home Based Services (respite only, not health insurance)<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-4882-field_52-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-trigger\" data-field-id=\"52\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Alabama Cares<\/legend><ul id=\"wpforms-4882-field_52\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_52_1\" name=\"wpforms[fields][52][]\" value=\"Alabama Cares\" aria-errormessage=\"wpforms-4882-field_52_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_52_1\">Alabama Cares<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-4882-field_53-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-trigger\" data-field-id=\"53\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">HEARTS<\/legend><ul id=\"wpforms-4882-field_53\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_53_1\" name=\"wpforms[fields][53][]\" value=\"HEARTS\" aria-errormessage=\"wpforms-4882-field_53_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_53_1\">HEARTS<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-4882-field_54-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-trigger\" data-field-id=\"54\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Alabama Head Injury Foundation<\/legend><ul id=\"wpforms-4882-field_54\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_54_1\" name=\"wpforms[fields][54][]\" value=\"Alabama Head Injury Foundation\" aria-errormessage=\"wpforms-4882-field_54_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_54_1\">Alabama Head Injury Foundation<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-4882-field_51-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"51\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-4882-field_51\">Date:<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-4882-field_51\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][51][date]\" aria-errormessage=\"wpforms-4882-field_51-error\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-4882-field_55-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"55\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-4882-field_55\">Date:<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-4882-field_55\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][55][date]\" aria-errormessage=\"wpforms-4882-field_55-error\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-4882-field_56-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"56\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-4882-field_56\">Date:<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-4882-field_56\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][56][date]\" aria-errormessage=\"wpforms-4882-field_56-error\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-4882-field_57-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"57\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-4882-field_57\">Date:<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-4882-field_57\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][57][date]\" aria-errormessage=\"wpforms-4882-field_57-error\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-4882-field_58-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-trigger\" data-field-id=\"58\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Veteran\u2019s Administration (Aid and Attendance)<\/legend><ul id=\"wpforms-4882-field_58\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_58_1\" name=\"wpforms[fields][58][]\" value=\"Veteran\u2019s Administration (Aid and Attendance)\" aria-errormessage=\"wpforms-4882-field_58_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_58_1\">Veteran\u2019s Administration (Aid and Attendance)<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-4882-field_59-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-trigger\" data-field-id=\"59\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Autism Society of AL<\/legend><ul id=\"wpforms-4882-field_59\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_59_1\" name=\"wpforms[fields][59][]\" value=\"Autism Society of AL\" aria-errormessage=\"wpforms-4882-field_59_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_59_1\">Autism Society of AL<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-4882-field_60-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-trigger\" data-field-id=\"60\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">ALS<\/legend><ul id=\"wpforms-4882-field_60\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_60_1\" name=\"wpforms[fields][60][]\" value=\"ALS\" aria-errormessage=\"wpforms-4882-field_60_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_60_1\">ALS<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-4882-field_61-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-trigger\" data-field-id=\"61\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Otro (nombre del programa):<\/legend><ul id=\"wpforms-4882-field_61\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4882-field_61_1\" name=\"wpforms[fields][61][]\" value=\"Other\" aria-errormessage=\"wpforms-4882-field_61_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_61_1\">Other<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-4882-field_62-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"62\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-4882-field_62\">Date:<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-4882-field_62\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][62][date]\" aria-errormessage=\"wpforms-4882-field_62-error\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-4882-field_63-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"63\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-4882-field_63\">Date:<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-4882-field_63\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][63][date]\" aria-errormessage=\"wpforms-4882-field_63-error\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-4882-field_64-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"64\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-4882-field_64\">Date:<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-4882-field_64\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][64][date]\" aria-errormessage=\"wpforms-4882-field_64-error\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-4882-field_66-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"66\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-4882-field_66\">Name of Program<\/label><input type=\"text\" id=\"wpforms-4882-field_66\" class=\"wpforms-field-medium\" name=\"wpforms[fields][66]\" aria-errormessage=\"wpforms-4882-field_66-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-25\"><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-4882-field_65-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"65\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-4882-field_65\">Date:<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-4882-field_65\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][65][date]\" aria-errormessage=\"wpforms-4882-field_65-error\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-4882-field_38-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"38\"><label class=\"wpforms-field-label\" for=\"wpforms-4882-field_38\">10. \u00bfCu\u00e1l es tu idioma principal?  Ingle<\/label><input type=\"text\" id=\"wpforms-4882-field_38\" class=\"wpforms-field-large\" name=\"wpforms[fields][38]\" aria-errormessage=\"wpforms-4882-field_38-error\" ><\/div><div id=\"wpforms-4882-field_114-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"114\"><div id=\"wpforms-4882-field_114\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-4882-field_114-error\"><p><strong>\u00bfPreguntas? Env\u00ede un correo electr\u00f3nico a al.respite@ucphuntsville.org o llame al 256-<\/strong><br \/>\n<strong>859-8300<\/strong><\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-4882-field_115-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"115\"><div id=\"wpforms-4882-field_115\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-4882-field_115-error\"><p><strong>Lea atentamente y coloque sus iniciales en cada caso:<\/strong><\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-4882-field_152-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"152\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-4882-field_135-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"135\"><div id=\"wpforms-4882-field_135\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-4882-field_135-error\"><p>Entiendo que, para recibir el reembolso, mi hoja de horas debe completarse y devolverse antes de la fecha de vencimiento proporcionada.<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-4882-field_136-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"136\"><div id=\"wpforms-4882-field_136\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-4882-field_136-error\"><p>Entiendo que soy responsable de seleccionar y capacitar a un proveedor de relevo confiable que tenga 18 a\u00f1os y viva fuera del hogar del beneficiario de la atenci\u00f3n. Ni AL Respite ni UCP ser\u00e1n responsables de las acciones que tome mi proveedor de relevo seleccionado.<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-4882-field_137-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"137\"><div id=\"wpforms-4882-field_137\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-4882-field_137-error\"><p>Los cheques de reembolso se enviar\u00e1n por correo a la direcci\u00f3n registrada en la hoja de horas enviada y puede haber un per\u00edodo de espera de 90<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-4882-field_138-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"138\"><div id=\"wpforms-4882-field_138\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-4882-field_138-error\"><p>Estoy de acuerdo en usar estos fondos SOLAMENTE para el cuidado de relevo.<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-4882-field_139-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"139\"><div id=\"wpforms-4882-field_139\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-4882-field_139-error\"><p>Entiendo que esta solicitud no ser\u00e1 procesada a menos que haya proporcionado prueba del diagn\u00f3stico de un m\u00e9dico, enfermera o trabajador social en papel con membrete.<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-4882-field_140-container\" class=\"wpforms-field wpforms-field-file-upload\" data-field-id=\"140\"><label class=\"wpforms-field-label\" for=\"wpforms-4882-field_140\">Se adjunta prueba de diagn\u00f3stico: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div\n\t\tclass=\"wpforms-uploader wpforms-field-required\"\n\t\tdata-field-id=\"140\"\n\t\tdata-form-id=\"4882\"\n\t\tdata-input-name=\"wpforms_4882_140\"\n\t\tdata-extensions=\"jpg,jpeg,jpe,gif,png,bmp,tiff,tif,webp,avif,ico,heic,heif,heics,heifs,asf,asx,wmv,wmx,wm,avi,divx,mov,qt,mpeg,mpg,mpe,mp4,m4v,ogv,webm,mkv,3gp,3gpp,3g2,3gp2,txt,asc,c,cc,h,srt,csv,tsv,ics,rtx,css,vtt,mp3,m4a,m4b,aac,ra,ram,wav,x-wav,ogg,oga,flac,mid,midi,wma,wax,mka,rtf,pdf,class,tar,zip,gz,gzip,rar,7z,psd,xcf,doc,pot,pps,ppt,wri,xla,xls,xlt,xlw,mpp,docx,docm,dotx,dotm,xlsx,xlsm,xlsb,xltx,xltm,xlam,pptx,pptm,ppsx,ppsm,potx,potm,ppam,sldx,sldm,onetoc,onetoc2,onepkg,oxps,xps,odt,odp,ods,odg,odc,odb,odf,wp,wpd,key,numbers,pages\"\n\t\tdata-max-size=\"52428800\"\n\t\tdata-max-file-number=\"1\"\n\t\tdata-post-max-size=\"52428800\"\n\t\tdata-max-parallel-uploads=\"4\"\n\t\tdata-parallel-uploads=\"true\"\n\t\tdata-file-chunk-size=\"2097152\">\n\t<div class=\"dz-message\">\n\t\t<svg  viewBox=\"0 0 640 640\" focusable=\"false\" data-icon=\"inbox\" width=\"50px\" height=\"50px\" fill=\"currentColor\" aria-hidden=\"true\">\n\t\t\t<path d=\"M352 173.3L352 384C352 401.7 337.7 416 320 416C302.3 416 288 401.7 288 384L288 173.3L246.6 214.7C234.1 227.2 213.8 227.2 201.3 214.7C188.8 202.2 188.8 181.9 201.3 169.4L297.3 73.4C309.8 60.9 330.1 60.9 342.6 73.4L438.6 169.4C451.1 181.9 451.1 202.2 438.6 214.7C426.1 227.2 405.8 227.2 393.3 214.7L352 173.3zM320 464C364.2 464 400 428.2 400 384L480 384C515.3 384 544 412.7 544 448L544 480C544 515.3 515.3 544 480 544L160 544C124.7 544 96 515.3 96 480L96 448C96 412.7 124.7 384 160 384L240 384C240 428.2 275.8 464 320 464zM464 488C477.3 488 488 477.3 488 464C488 450.7 477.3 440 464 440C450.7 440 440 450.7 440 464C440 477.3 450.7 488 464 488z\"\/>\n\t\t<\/svg>\n\n\t\t<span class=\"modern-title\">\n\t\t\t\t\t\t\tDrag &amp; Drop Files, \t\t\t\t<span>Choose Files to Upload<\/span>\n\t\t\t\t\t<\/span>\n\n\t\t\t<\/div>\n<\/div>\n\n<input\n\t\ttype=\"text\"\n\t\tautocomplete=\"off\"\n\t\treadonly\n\t\tclass=\"dropzone-input\"\n\t\tstyle=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\"\n\t\tid=\"wpforms-4882-field_140\"\n\t\tname=\"wpforms_4882_140\" required\t\tvalue=\"\">\n<\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-4882-field_141-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"141\"><div id=\"wpforms-4882-field_141\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-4882-field_141-error\"><p><strong>Informaci\u00f3n del destinatario de la atenci\u00f3n: <\/strong><\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-4882-field_142-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"142\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-4882-field_143-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"143\"><label class=\"wpforms-field-label\" for=\"wpforms-4882-field_143\">Apellido: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4882-field_143\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][143]\" aria-errormessage=\"wpforms-4882-field_143-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-4882-field_144-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"144\"><label class=\"wpforms-field-label\" for=\"wpforms-4882-field_144\">Primer nombre, inicial del segundo nombre: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4882-field_144\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][144]\" aria-errormessage=\"wpforms-4882-field_144-error\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-4882-field_153-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"153\"><div id=\"wpforms-4882-field_153\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-4882-field_153-error\"><h4>Add Text and Images to Your Form With Ease<\/h4>\n<p>To get started, replace this text with your own.<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-4882-field_147-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"147\"><label class=\"wpforms-field-label\" for=\"wpforms-4882-field_147\">Fecha de nacimiento: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-4882-field_147\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][147][date]\" aria-errormessage=\"wpforms-4882-field_147-error\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-4882-field_148-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"148\"><fieldset><legend class=\"wpforms-field-label\">G\u00e9nero: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-4882-field_148\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-4882-field_148_1\" name=\"wpforms[fields][148]\" value=\"Femenino\" aria-errormessage=\"wpforms-4882-field_148_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_148_1\">Femenino<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-4882-field_148_2\" name=\"wpforms[fields][148]\" value=\"Masculino\" aria-errormessage=\"wpforms-4882-field_148_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_148_2\">Masculino<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-4882-field_148_3\" name=\"wpforms[fields][148]\" value=\"Otra\" aria-errormessage=\"wpforms-4882-field_148_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4882-field_148_3\">Otra<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-4882-field_149-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"149\"><label class=\"wpforms-field-label\" for=\"wpforms-4882-field_149\">Raza: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4882-field_149\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][149]\" aria-errormessage=\"wpforms-4882-field_149-error\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-4882-field_150-container\" class=\"wpforms-field wpforms-field-signature\" data-field-id=\"150\"><label class=\"wpforms-field-label\" for=\"wpforms-4882-field_150\">Firma del cuidador principal: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4882-field_150\" class=\"wpforms-signature-input wpforms-screen-reader-element wpforms-field-required\" data-is-wrapped-field=\"1\" name=\"wpforms[fields][150]\" autocomplete=\"off\" inputmode=\"none\" aria-errormessage=\"wpforms-4882-field_150-error\" required><div class=\"wpforms-signature-wrap wpforms-field-row wpforms-field-large\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-4882-field_150-signature\" data-color=\"#000000\"><\/canvas><div class=\"wpforms-signature-clear\" title=\"Clear Signature\" tabindex=\"0\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"1em\" height=\"1em\" preserveAspectRatio=\"xMidYMid meet\" viewBox=\"0 0 1536 1536\">\n\t\t\t\t\t<path fill=\"var( --wpforms-field-text-color, rgba(0, 0, 0, 0.25) )\" d=\"M1149 994q0-26-19-45L949 768l181-181q19-19 19-45q0-27-19-46l-90-90q-19-19-46-19q-26 0-45 19L768 587L587 406q-19-19-45-19q-27 0-46 19l-90 90q-19 19-19 46q0 26 19 45l181 181l-181 181q-19 19-19 45q0 27 19 46l90 90q19 19 46 19q26 0 45-19l181-181l181 181q19 19 45 19q27 0 46-19l90-90q19-19 19-46zm387-226q0 209-103 385.5T1153.5 1433T768 1536t-385.5-103T103 1153.5T0 768t103-385.5T382.5 103T768 0t385.5 103T1433 382.5T1536 768z\"\/>\n\t\t\t\t<\/svg>\n\t\t\t\t<div class=\"wpforms-signature-clear-caption\">Clear Signature<\/div>\n\t\t\t<\/div><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-4882-field_151-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"151\"><label class=\"wpforms-field-label\" for=\"wpforms-4882-field_151\">Fecha: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-4882-field_151\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][151][date]\" aria-errormessage=\"wpforms-4882-field_151-error\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><\/div><\/div><script>\n\t\t\t\t( function() {\n\t\t\t\t\tconst style = document.createElement( 'style' );\n\t\t\t\t\tstyle.appendChild( document.createTextNode( '#wpforms-4882-field_2-container { position: absolute !important; overflow: hidden !important; display: inline !important; height: 1px !important; width: 1px !important; z-index: -1000 !important; padding: 0 !important; } #wpforms-4882-field_2-container input { visibility: hidden; } #wpforms-conversational-form-page #wpforms-4882-field_2-container label { counter-increment: none; }' ) );\n\t\t\t\t\tdocument.head.appendChild( style );\n\t\t\t\t\tdocument.currentScript?.remove();\n\t\t\t\t} )();\n\t\t\t<\/script><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"4882\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/alabamarespite.org\/es\/wp-json\/wp\/v2\/pages\/4936\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-4882\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img loading=\"lazy\" decoding=\"async\" src=\"data:image\/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==\" data-layzr=\"https:\/\/alabamarespite.org\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Cargando\"><\/div><\/form><\/div>  <!-- .wpforms-container -->\r\n\r\n<\/p>\r\n<p style=\"text-align: center;\">Env\u00ede por correo electr\u00f3nico el formulario completo a: <a href=\"mailto:al.respite@ucphuntsville.org\">al.respite@ucphuntsville.org<\/a><br \/>O (No ambos)<br \/>Env\u00ede por correo el formulario completo a: Alabama Respite, 1856 Keats Dr. NW,<br \/>Huntsville, AL 35810<\/p>\r\n<p style=\"text-align: center;\">\r\n\r\n<\/p>\r\n<p style=\"text-align: center;\">\u00bfPreguntas? Env\u00ede un correo electr\u00f3nico a al.respite@ucphuntsville.org o llame al 256-<br \/>859-8300<\/p>\r\n<p><\/p>","protected":false},"excerpt":{"rendered":"<p>\u00bfEs usted un cuidador familiar (padre, guardi\u00e1n o familiar) sin compensaci\u00f3n monetaria por los cuidados de tiempo completo a un ser querido de cualquier edad con una enfermedad cr\u00f3nica o discapacidad que requiere atenci\u00f3n las 24 horas? \u00bfNecesita un descanso (tambi\u00e9n conocido como respiro)? Si es as\u00ed, lo invitamos a * solicitar el programa de &hellip; <\/p>","protected":false},"author":3,"featured_media":0,"parent":556,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_price":"","_stock":"","_tribe_ticket_header":"","_tribe_default_ticket_provider":"","_tribe_ticket_capacity":"0","_ticket_start_date":"","_ticket_end_date":"","_tribe_ticket_show_description":"","_tribe_ticket_show_not_going":false,"_tribe_ticket_use_global_stock":"","_tribe_ticket_global_stock_level":"","_global_stock_mode":"","_global_stock_cap":"","_tribe_rsvp_for_event":"","_tribe_ticket_going_count":"","_tribe_ticket_not_going_count":"","_tribe_tickets_list":"[]","_tribe_ticket_has_attendee_info_fields":false,"footnotes":""},"class_list":["post-4936","page","type-page","status-publish","hentry","latest_post"],"_links":{"self":[{"href":"https:\/\/alabamarespite.org\/es\/wp-json\/wp\/v2\/pages\/4936","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/alabamarespite.org\/es\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/alabamarespite.org\/es\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/alabamarespite.org\/es\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/alabamarespite.org\/es\/wp-json\/wp\/v2\/comments?post=4936"}],"version-history":[{"count":0,"href":"https:\/\/alabamarespite.org\/es\/wp-json\/wp\/v2\/pages\/4936\/revisions"}],"up":[{"embeddable":true,"href":"https:\/\/alabamarespite.org\/es\/wp-json\/wp\/v2\/pages\/556"}],"wp:attachment":[{"href":"https:\/\/alabamarespite.org\/es\/wp-json\/wp\/v2\/media?parent=4936"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}